You’re expecting a baby and you’re over the moon – and probably a bit apprehensive.
Or maybe you’re struggling with anxiety and depression.
Postpartum depression seems to be on everyone’s radar, but what about an expectant mother’s mental health? And what impact is the pandemic having on their sense of well-being?
A McGill-initiated longitudinal study is looking at the entire continuum, following women in pregnancy until eight months post-partum. Nearly 1,000 women and counting are enrolled in the Montreal Antenatal Well-Being Study.
The researchers aim to gain insight into which combination of factors – biological, social and psychological – make some women more likely to experience anxiety and depression in pregnancy and after giving birth.
They also hope to examine the potential impact of mental health struggles in pregnancy on child outcomes.
“We’re trying to refine the screening of mental health in pregnancy so that we can intervene as early as possible and prevent the dips that we see post-partum,” says Dr. Tuong-Vi Nguyen, an assistant professor in the Department of Psychiatry at McGill and the study’s co-lead.
It’s not too late to intervene once the baby is born, but it’s harder “because everyone is in a crisis, everyone is tired,” says Nguyen, a reproductive psychiatrist and clinician-scientist at the Research Institute of the McGill University Health Centre (RI-MUHC).
Of the women who experience post-partum depression, at least half start showing symptoms in pregnancy, she says.
Estimated one in five pregnant women experience mental health difficulties
Estimates vary on how many women will struggle with their mental health in pregnancy, says Kieran O’Donnell, an adjunct professor in the Department of Psychiatry at McGill who is leading the Ludmer Centre for Neuroinformatics & Mental Health’s study. They range from approximately one in five, which is seen across multiple studies, he says, to as many as one in three women, especially with high risk samples.
Preliminary results from the Montreal study show a higher percentage of psychological distress than expected compared to prior pregnancy cohorts. Approximately 15 per cent showed levels consistent with clinical levels of depression throughout the course of the study. Another 15 per cent displayed moderate sub-clinical depressive symptoms. “This suggests approximately a third of women at the start of pregnancy would benefit from some level of support with regards to their mental health,” O’Donnell says.
There is no universal screening for mental health in pregnancy in Quebec and many parts of Canada, laments O’Donnell. That goes against recommendations in place in the U.K. and Australia, he says.
In conjunction with the study, a systematic screening algorithm and intervention protocol was recently implemented at the McGill University Health Centre (MUHC), Nguyen says.
“If our study can validate [the algorithm’s] use during pregnancy, this screening tool could eventually be implemented across the province. But first we need to determine what are the best predictors of maternal mental health, and how a woman’s risk profile can be matched to tailored, more relevant interventions. And that’s what the study is trying to do,” she says.
Researchers also collect a DNA sample from study participants.
Even if they measure psychosocial variables such as personality, attachment and mental health symptoms, “the resulting algorithm might still miss mothers with greater mental health vulnerability due to genetic or epigenetic factors. The goal would be to combine both biological and psychosocial factors in the same screening tool, and this could be relatively easy (and pain-free) with a buccal swab for DNA,” Nguyen explains.
Epigenetics refers to a series of chemical marks or modifications – that sit on, or close to, our DNA – that can change the way our genome functions.
“We’re really trying to understand at multiple levels ranging from biology all the way to the social environment, what are the factors that are important for women’s mental health in pregnancy and in the post-natal period,” O’Donnell says.
COVID-19 and pandemic stress
The study involves four birthing centres in Montreal with different demographics, which is one of its strengths, according to Nguyen. The birthing centres are located at the MUHC, St. Mary’s, LaSalle and Sainte-Justine hospitals.
Women complete detailed questionnaires on multiple aspects of their mental health such as stress, anxiety, depression and local support.
The study began as a pilot project in August 2019. When the pandemic hit, researchers incorporated COVID-related questions. They also sent the women a snapshot survey last spring to ask how they were coping in the midst of a pandemic and their pregnancy.
“What we found so far is that perhaps not surprisingly the pandemic has increased women’s anxiety levels. And it has increased their perceived stress levels,” O’Donnell said in mid-July.
“We know that women who have high levels of anxiety in pregnancy have approximately three times the risk for post-partum depression.”
By early fall, Nguyen noted that, unlike other catastrophes such as the well-studied Quebec Ice Storm of 1998, the pandemic can be divided into two waves – the first associated with potentially an acute increase in stress levels while the second wave may be linked to more chronic, low-level stress. Prior animal and molecular studies suggest that acute and chronic stress have different effects on the mother and unborn baby (not to mention the father), she says.
Not all stress is bad, says Nguyen who points out some level of stress is part of life. “The problem is no one knows where the optimal zone is,” and the optimal stress ‘window’ most likely varies depending on the individual mother.
Potential impact on the unborn child?
Researchers hope to obtain funding to study the potential impact of women’s mental health on child outcomes, including the additional effect of pandemic-associated stress.
Scientists from the Douglas Mental Health University Institute and McGill detected a distinctive ‘signature’ in the DNA of children born in the aftermath of Quebec’s devastating Ice Storm. They concluded for the first time that maternal hardship predicted the degree of methylation of DNA in T cells, a type of immune system cell.
“There is a multitude of adverse outcomes that are associated with women’s stress during pregnancy or women’s mental health problems in pregnancy,” O’Donnell says. “What I think is fascinating about those findings is that not all children are affected. And those children that are affected can be affected in very different ways.”
Research he carried out in the U.K. showed that children born to women who experienced high levels of anxiety or depression in pregnancy have about twice the risk for emotional and behavioral difficulties. “And we see those effects as early as four years of age and they persist until at least early adulthood,” says O’Donnell, now an assistant professor at the Yale Child Study Center and Yale School of Medicine.
O’Donnell took pains to emphasize – and reassure any pregnant women reading this article – that most children are not affected.
But we need to better understand why some are, he says, “and what are the factors that we can actually intervene on to stop that from happening.”
The Ludmer Centre for Neuroinformatics & Mental Health is an innovative collaboration between the Douglas Mental Health University Institute (Douglas) Research Centre, the Jewish General Hospital’s Lady Davis Institute for Medical Research, and McGill’s Montreal Neurological Institute. The Montreal Antenatal Well-Being Study is partially funded by Healthy Brains, Healthy Lives, a high-priority initiative at McGill that builds on the University’s scientific excellence and global leadership in areas of neuroscience that hold the greatest promise for delivering implementable, clinically effective outcomes in brain and mental health.